Westlake, OH

• Who Needs Care at Home?*
  Select OneMyselfSpouseParentGrandparentOther RelativeFriendOther
• How Old is the Person Who Needs Care?*
  Select One45-5455-6465-7475-8485 or older
• Male or Female?*
  Select OneMaleFemale
• Estimate How Much Care They Might Need*
  Select OneA few hours per weekMore than 20 hours per week40 or more hours per weekAround-the-Clock CareLive-In Care
• How will care be paid for?*
  • Private Funds
  • Long-Term Care Insurance
  • Medicaid
  • Other - (VA Aid and Attendance, Reverse Mortgage, etc)
• Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?*
  • Yes
  • No
  • I don't know
• Zip Code Where Care is Needed*
• Name of Person Submitting this Form*
  First Last
• Your Email Address- We will send you information via email.*
• Phone Number of Person Submitting this Form*
• CAPTCHA